A drug addict regularly consults the out-of-hours doctors requesting a repeat prescription of diazepam. He says he is in the process of registering with a GP and claims that his recent prescriptions were stolen from him. He has once been overheard on his mobile phone selling his prescriptions.
What would you do?
Prescribing only a limited supply of diazepam may be most appropriate
Dr Amit Tiwari's view
This is a difficult question without any clear background except the patient's word.
Is this personal drug-seeking behaviour or a business selling drugs illegally for profit?
It may have been going on for some time and he may be using multiple agencies for the same problems, such as A&E, other local out-of-hours providers or local pharmacies. The important thing is to obtain the facts and ensure this behaviour stops.
In this case, it is imperative to get the old notes from the out-of-hours service and check through for the number of times he has done this, how long it has been going on for and what amounts were supplied. How long ago did he have his last scrip?
Ideally, I would want to start some communication with other agencies to find out if he is using multiple sources. The pharmacy should be able to give an idea of whether or not he actually got his last prescription, which he claims was stolen from him.
It would also be imperative to find out the last place he was registered as a patient, and to establish if he has ever been on a long-term repeat prescription for diazepam and why.
This might not be practical to do in a busy out-of-hours setting, in which case I would leave the patient details and problem with the PCT to ensure there was some follow-up of this patient, and to take further action as appropriate. They could then also notify all agencies more easily to make them aware of this patient.
I would ask them to keep me in the loop with the correspondence so that I was sure something was being done about this situation.
In this case, I would see the patient after getting as much information as possible, take a detailed history of his reasons for needing diazepam, what dosage and if he gets help from other agencies for his problems.
I would not give him a month's supply of the medication. I would only prescribe enough to last until the next working day. I would advise him that it is inappropriate for him to keep coming to the out-of-hours clinic for prescriptions and that he needs to register with a GP to be able to get any more long-term prescriptions.
I would then put a note on his file to ensure that he only receives a minimal supply to last him until the next working day so that all doctors were consistent in their treatment of this patient.
- Dr Tiwari is a GP principal in Colchester. He qualified as a GP in 2007
Dr Barney Tinsley's view
There are several factors that might influence the clinician's decision and ultimate management plan in this situation.
Does the doctor have access to any electronic records about this individual? In our local out-of-hours centre, many practices use the same recording system, and so prescription history, previous attendances and other useful clinical information are available, including the location and actions of recent or current GPs.
The facility to place an 'alert' on the front or demographic page of the records to warn unfamiliar clinicians may be of great assistance.
Does the out-of-hours centre have a policy on drug-seeking behaviour? Unfortunately, a proportion of drug addicts will display devious, underhand, manipulative and occasionally threatening behaviour to meet their demands.
Clinicians and support staff should not tolerate threatening behaviour and should adopt a zero tolerance approach where possible.
In this case, the drug in question, diazepam, would not be deemed vital to this patient, can have serious or even fatal effects in overdose and is known to have significant addictive potential. Were it true that this patient was selling on prescriptions, others may also be at risk from the negative effects of diazepam.
What else is this patient addicted to? Concomitant usage of diazepam with, for example, IV heroin can lead to serious respiratory depression, coma and death.
This patient should register with a practice specialising in drug addiction prescribing, and could be signposted to local support services for help with his addiction. I would resist prescribing for this patient in the out-of-hours setting.
- Dr Tinsley is a salaried GP in Bradford. He qualified as a GP in 2005
Dr Fola Olaleye's view
The conflict here lies between the duty of care to the patient and the duty to society.
A GP has to do all he or she can to cut down on the availability of prescribed medications on the black market.
It is not always easy to recognise which patients genuinely need medication. In this particular case, it is apparent that the patient is a dealer. However, he may also need the medication for a genuine problem.
In the first instance, I would want to see proof that he has been using this medication himself: for example, old prescription counterfoils and proof of identity. I would also want to telephone the previous GP surgery to check out his story.
If indeed I was convinced that he needed the medication I would prescribe only a limited quantity.
This approach works well because the cost of the frequent trips to the out-of-hours clinic is likely to make his trade unprofitable and encourage him to register with a GP, while at the same time, not neglecting my duty of care.
Dr Olaleye is a GP in Medway. He qualified as a GP in 2006
- This topic falls under section 15.3 of the GP curriculum 'Drug and Alcohol Problems', www.rcgp-curriculum.org.uk
- Contact Emma Quigley at GP Education on (020) 8267 4805 or email GPeducation@haymarket.com
Miss T is a regular caller to the out-of-hours service. In the past year she has made over 1,000 telephone calls about a chest pain, requesting home visits. Previous home visits have not uncovered any emergencies. Her GP has issued a note saying that only immediate problems should be attended to because her mental health issues are being adequately managed.
She calls, as usual about a chest pain, and requests a home visit. You are the doctor on duty.
What would you do?
- Email GPeducation@haymarket.com with your replies by 5 December 2008. We will pay £25 for each reply published.